ANNEXURE 69

FORM - AI
[See Rule 2 (c) of Consumer Welfacer Fund rules, 1992]

IMPORTANT: Please fill up this form, furnishing correct details sought for, based on verifiable true state of affairs without causing suppression of any material information which if resorted to, shall entail prosecution under the Act.

Note : All applications must be submitted along with their enclosures in duplicate duly attested by any gazetted officer of the Central or State Government.

1. Name and full postal address of the applicant	:
2. Status of the applicant under clause (b) of Rule 2	:
3. Date of establishment	:
4. Whether registered under the Societies Registration Act, 1860 (21 of 1860) or any other relevant Act	:
5. If yes, number and year of registration (Attested copy of registration certificate to be enclosed)	:
6. Whether the organisation is of national or State level	:
7. Number of Managing Committee members together with list of names, address and occupation of the office bearers	:
8. Brief details of the organisation, objectives and activites during the last three years	:
9. Purpose for which the amount is required (please state the details of the project and its proposed implemention)	:
10. Amount of grant required - itemwise details under non-recurring, recurring to be enclosed	:
11. Time Schedule of the activities arranged	:
12. The total amount incurred or invested by the applicant, or likely to be incurred by the applicant	:
13. Sources of funding of balance amount whether the organisation is getting financial assistance from any other official or non-official source, if yes, give details	:
14. Details of prosecution, if any, in a court of law launched against the applicant, during the last five years.	:
15. Copies of the following documents (duly attested by a gazetted officer of the Central or State Government ) to be attached) -	:

(i) Constitution of the organisation and Articles of Association.

(ii) Annual reports of the organisation fro last three years (please furnish separte Annual Reports for each year).

(iii) Annual audited Statement of accounts for each of last 3 years duly signed by Chartered Accountant. These Statements must bear the registration number and official seal or stamp of the Chartered Accountant.

DECLARATION

(To be signed by the applicant or its authorised agent)

The particulars heretofore given, are true and correct. Nothing material has been suppressed. It is certified that I/ we have read the guidelines, terms and conditions governing the scheme and undertake to abide by them on behalf of our organisation / institution. The financial assistance, if provided, shall be put to the declared use, for promotion and protection of rights of consumers or for standard marks. (Strike out whichever is inapplicable).

Applicant

Dated :
Station :

To,

Member-Secretary
Committee (Consumer Welfare Fund)
Krishi Bhawan
New Delhi

Recommendation of Member-Secretary

Factual details furnished in the application have been verified in consultation with Ministry / Department of agency who is / are administratively converned in the matter and found to be correct / incorrect. The claims of the applicant are recommended for consideration by the Committee (Please give reasons in support of your recommendation).

Member-Secretary
Committee (Consumer Welfare Fund)

Recommendation of the CommitteeRecommended for grant of Rs. _________ Rupees _____________________ _____________________________ (in words ) from the Consumer Welfare Fund as discussed in the meeting held on _____________ (date)

Chairman
Committee.